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Abstract

Background

Mental health related presentations are common in Australian Emergency Departments
(EDs). We sought to better understand ED staff knowledge and levels of confidence
in treating people with mental health related problems using qualitative methods.

Methods

This was a qualitative learning needs analysis of Australian emergency doctors and
nurses regarding the assessment and management of mental health presentations. Participants
were selected for semi-structured telephone interview using criterion-based sampling.
Recruitment was via the Australasian College for Emergency Medicine and College of
Emergency Nursing Australasia membership databases. Interviews were audio-recorded
and transcribed verbatim. Thematic framework analysis was used to identify perceived
knowledge gaps and levels of confidence among participants in assessing and managing
patients attending EDs with mental health presentations.

Results

Thirty-six staff comprising 20 doctors and 16 nurses consented to participate. Data
saturation was achieved for four major areas where knowledge gaps were reported. These
were: assessment (risk assessment and assessment of mental status), management (psychotherapeutic
skills, ongoing management, medication management and behaviour management), training
(curriculum and rotations), and application of mental health legislation. Participants’
confidence in assessing mental health patients was affected by environmental, staff,
and patient related factors. Clinicians were keen to learn more about evidence based
practice to provide better care for this patient group. Areas where clinicians felt
the least confident were in the effective assessment and management of high risk behaviours,
providing continuity of care, managing people with dual diagnosis, prescribing and
effectively managing medications, assessing and managing child and adolescent mental
health, and balancing the caseload in ED.

Conclusion

Participants were most concerned about knowledge gaps in risk assessment, particularly
for self-harming patients, violent and aggressive patients and their management, and
distinguishing psychiatric from physical illness. Staff confidence was enhanced by
better availability of skilled psychiatric support staff to assist in clinical decision-making
for complex cases and via the provision of a safe ED environment. Strategies to enhance
the care of patients with mental health presentations in Australian emergency departments
should address these gaps in knowledge and confidence.

Keywords:

Background

Mental health related problems are estimated to account for between 3 to 5% of Emergency
Department visits in Australia
[1-3]. In a recent mental health-related learning needs analysis of clinicians working
in Australian public sector EDs, we reported a lack of knowledge and confidence in
managing mental health related presentations. The gaps were very similar between emergency
doctors and nurses, with nurses rating both knowledge and confidence lower than doctors
[4]. Clinicians reported particular concern about managing patients presenting to EDs
with personality disorder, psychosis or behavioural disturbance. They perceived knowledge
deficits in developing care plans, conducting mental status examinations, assessing
risk for self-harm, pharmacological management, responding effectively to patient
aggression and alcohol or drug intoxication.

The current research was undertaken as part of a national qualitative survey of emergency
nurses’ and doctors’ perceived learning needs regarding the assessment and management
of patients with mental health conditions in Australian EDs. Findings from this study
have previously been reported in relation to the optimal management of mental health
related presentations, barriers to operation of mental health legislation, management
of mental health conditions in rural and remote settings and the triage of mental
health related problems
[5-8]. In this particular study, we explore the perceived knowledge gaps of ED staff and
the areas in which they lacked confidence in assessing and managing people presenting
with mental health conditions. We aimed to use qualitative methods to more deeply
explore issues around these clinicians’ knowledge and confidence in this area of emergency
medicine.

Methods

Design

This was a qualitative learning needs analysis. Semi-structured telephone interviews
were conducted with ED doctors and nurses. The research was approved by the Human
Research and Ethics Committees (Faculty of Health Sciences) at La Trobe University
and the Human Research Ethics Committee at St Vincent’s Hospital Melbourne. Study
oversight was by a research team with meetings, and email contact, to oversee development
of the interview schedule and data analyses. Detailed accounts of methods employed
have previously been published
[5-8].

Participants

Participants working in a clinical role in an Australian ED and members of either
the Australasian College for Emergency Medicine (ACEM; emergency doctors) or the College
of Emergency Nurses Australasia (CENA; emergency nurses) were invited to take part
in a telephone interview. We attempted to achieve proportional distribution of participants
by location (metropolitan, regional/rural) and Australian states and territories by
using a criterion-based sampling frame
[9].

Interview schedule

The research team including two emergency physicians, a researcher/emergency nurse,
a research psychologist and a research officer used a consensus panel approach
[9] to develop the semi-structured telephone interview schedule based on review of available
literature. This included 16 open-ended interview questions to elicit participant’s
views on a variety of clinician issues around mental health presentations to EDs.
This part of the study examined the participants’ knowledge and confidence in assessing
and managing people with mental health-related presentations in response to four specific
questions.

1. What knowledge deficits do you feel that you or other emergency department clinicians
have in respect to the assessment and management of mental health related presentations?

2. Do you think that emergency department clinicians would be interested in learning
more about these conditions?

4. In which areas do you feel least confident in assessing and treating mental health
related problems?

Recruitment

Emergency department clinicians were contacted via email. The initial invitation to
participate was sent by ACEM and CENA to financial members. For those who expressed
an interest, a plain language statement and participant information and consent form
were emailed explaining the study in more detail. Following consent the interview
questions were emailed in order to allow time to consider responses. Telephone interview
responses were audio-recorded and transcribed verbatim. Transcripts were emailed back
to participants to validate the credibility of the responses. One of the research
team, a female researcher with qualifications in social work in an ED, and experience
in qualitative methodologies conducted all telephone interviews.

Analysis

Thematic analysis of the transcribed data was performed by two research officers using
Spencer and Ritchie’s Framework method
[9], resulting in a systematic thematic analysis of participant responses regarding perceived
knowledge gaps regarding mental health-related presentations and the factors influencing
their confidence in assessing and managing these presentations.

Results

Participant characteristics

The expression of interest emails resulted in 71 responses from ED doctors and nurses
(39 ACEM and 32 CENA members), from which 20 ED doctors and 16 ED nurses were chosen
to be interviewed on the basis of achieving a balanced sample from metropolitan and
rural/regional EDs, the Australian states and territories, and ED seniority. Two thirds
of the participants (24/36) worked in metropolitan EDs, just under one third in rural/regional
locations (0/36) and 2 participants did not provide demographic data. One quarter
of ED doctors were working as ED Directors/Deputy ED Directors (5/20), 8 were staff
specialists and 7 were registrars. Table
1 shows the participants’ characteristics.

Table 1.Study participants’ characteristics by discipline, state or territory, and region

Perceived knowledge gaps

Knowledge deficits were identified in four major areas. These were: assessment (risk
assessment and mental state assessment), management (use of psycho-therapeutic skills,
ongoing management, medication management and behaviour management), training (curriculum
and rotations) and legislation.

Table
2 shows the major themes and sub-themes with sample quotes from study participants
regarding the assessment and management of mental health presentations.

With respect to sub-themes, five doctors and nine nurses identified risk assessment
as a key issue where they perceived knowledge levels to be inadequate. Specific knowledge
about the effective use of assessment tools was identified by two doctors and six
nurses.

….personally I could probably make use of [assessment] tools more. (M17)

Knowledge of current [assessment] tools is perhaps not what it should be. (M13)

Differentiating psychiatric disorders was identified as a theme by five doctors and
three nurses. Similarly formulating differential diagnoses was raised as an area of
concern as was dual diagnosis.

In terms of perceived knowledge gaps about the management of mental health related
presentations, the use of brief psychotherapeutic interventions was mentioned by five
doctors and one nurse.

…putting in place some strategies or some boundaries to say “ok, I know that you are
upset, I hear what you’re saying, this is what I can do about it, but what I need
you to do is this and this. That behaviour is not acceptable, if you do that this
is what is going to happen”. People just really shy away from that. (N6)

Knowledge gaps regarding medication management were identified as an issue for 11
doctors and three nurses. Sedation in particular was identified as an area in which
the participants felt they required greater knowledge.

I’ve never been properly taught in terms of who I should sedate, how I should sedate
them (IV, IM, orally) and when/what the implications are for sedation so I think I
would like to have some more guidelines for sedation. (M35)

Within this sub-theme four doctors identified new medications as a particular knowledge
deficit.

Certainly things like new medications…, there’s obviously been a change in medication
management… That sort of cutting edge stuff is stuff you hope you can stay abreast
of, but trouble is often you don’t know what deficits you may or may not have. (M17)

Despite participating in education and training, six doctors and six nurses suggested
behaviour management as a key area for improvement.

I did a one-day course on management of aggression training. It was quite useful about
talking to people, and trying to talk them down. It’s something that certainly ED
registrars would be good to have as part of their training… (N32)

I think often that needs more education - teaching and perhaps role-playing and that
sort of thing to learn about managing… And trying to defuse violence… (M9)

Two doctors identified psychiatric training in general as a key theme, one identifying
the trainee curriculum and the other rotation of junior medical staff as issues, and
seven doctors reported knowledge gaps in understanding mental health legislation
[6].

Confidence

Participants’ confidence in assessing mental health patients was influenced by environmental
factors (lack of resources and safety and security features of the environment), staff
levels of experience in managing mental health problems, and case complexity (psychiatric/physical
differentiation, accurate history, aggression, risk of self harm, dual diagnosis,
personality disorder). Clinicians were keen to learn more about evidence based practice
to provide better care for these patients.

Table
3 outlines the major themes and sub-themes on factors effecting confidence with sample
quotes from study participants to further demonstrate these themes.

Table 3.Factors perceived by participants to influence confidence in the assessment and management
of mental health related presentations

A total of 12 doctors and five nurses commented on lack of availability of resources
affecting their confidence in treating mental health patients.

A secure and safe environment was a sub-theme for four doctors and five nurses.

Exposure to mental health patients and the clinician’s experience managing them was
an important issue identified by nine doctors and four nurses.

…it’s really something to get used to over time. It really did used to make me quite
nervous when I first started working in medicine, and I was much less confident in
my decisions. I think it’s timely experience as much as anything… (M29)

Case complexity was also a factor reported to influence levels of confidence. In particular,
differentiating psychiatric from physical illness presented a challenge for six doctors
and three nurses.

…my confidence in diagnosis of psychiatric disorders in ED is extremely low, but I
do not view that as my main role in ED. (M19)

Patient aggression was a significant factor affecting the confidence of two doctors
and five nurses.

Aggression and anger is probably something I don’t deal with very well. (N16)

Risk assessment was a particular concern for four doctors and two nurses who commented
on the inconsistencies in the outcomes of risk assessments and associated dispositions.

The idea of someone who says that they can’t guarantee their safety but then making
the call that they’re probably OK to go home. That’s one thing I’m less confident
about. The . key . there is the risk associated with that… (M15)

Disposition decisions were an area of lack of confidence for four medical staff.

…if they come in and they’re feeling a bit vulnerable and I actually don’t really
feel they’re going to kill themselves, I do think they can go home back to the community
…, I must say I always discuss it with a psychiatrist… (M19)

In terms of specific diagnosis personality disorders was cited by five doctors and
one nurse as the area in which they had the least confidence.

… personality disorders who are having a bit of a crisis – that’s still a difficult
area for me… (M29)

…how to manage them [patients with personality disorders]can be difficult …. That’s
one of the trickiest ones… (M21)

As an organisation and as a department we have huge issues managing people who have
a long-standing personality disorder for example, and are presenting for treatment
for an acute medical condition. (N16)

Knowledge of available services was cited as a cause of lack of confidence by four
doctors, with these comments:

And also the knowledge of how to discharge patients into good outpatient care because
there are a range of outpatient initiatives in our region… (M13)

I don’t know as much about community resources as I would like to (M17)

Dual diagnosis

Dual diagnosis was a concern for four doctors and one nurse, particularly the combination
of drug and alcohol problems with mental health issues.

I suppose probably the least confident is where there is the combination of drug and
alcohol and mental health issues… (M5)

…especially if they come in and they’re under the influence of the drugs or intoxicated,
it does make it difficult to make the right assessment and safety issues… (N2)

Areas for education

In response to a question of whether the participant thought ED clinicians would be
interested in learning more about particular areas, participants reported that clinicians
were keen to learn more about evidence based best practice for these patients, in
addition to issues around legislation, counselling, sedation, and differentiating
between physical and psychiatric illness. Many clinicians (four doctors and five nurses)
commented that this would depend largely on the personality of the clinician, and
several (four doctors, one nurse) suggested that some attitudinal change might be
necessary.

Discussion

There is little literature on the knowledge and confidence of ED clinical staff in
the management of patients with mental health-related presentations, with the available
literature mostly relating to nurses. Small studies from the UK
[10] and Australia
[11] have shown that staff insecurities and culture can mean that mental health presentations
have a low status in EDs compared with more dramatic physical illness, with ED nurses
feeling a lack of skills and expertise to effectively manage this patient group. Cultural
and systemic change with the introduction of psychiatric liaison nurses was shown
to improve this situation
[11], with staff responding favourably to this intervention. Importantly, nurses in the
UK study identified a perceived deficit in mental health knowledge
[10]. Participants in the Australian study expressed through questionnaire responses a
particular lack of confidence in mental health triage, intoxicated and paranoid patients,
and those resisting treatment, but also in assessment skills, particularly for self-harming
patients
[11]. The study reported a generalised lack of confidence in interacting with mental health
patients.

One Western Australian study, stimulated by ED nurses having identified workplace
safety and aggression as a key issue, showed through focus group discussions that
ED nurses managing mental health patients identified customer focus, workplace aggression
and violence, psychiatric theory, mental health assessment and chemical dependence
as key learning areas
[12]. The recruitment posters for this study were titled ‘What do ED nurses need/want
in an education program to work effectively with aggressive or mental health presentations
to ED?’ and this may have skewed learning needs identified towards safety and aggression,
however other key issues identified in the focus groups were assessment and drug and
alcohol issues. Of note, participants expressed deep concern about inadequate management
of mental health patients in EDs, and felt that lack of knowledge was a key issue.

Our study has revealed an expressed range of perceived knowledge gaps and lack of
confidence of clinicians of all levels of clinical experience working in Australian
EDs in managing people with mental health-related presentations. In keeping with the
findings of a quantitative national study of the same target group of clinicians
[4], we found that risk assessment (notably for self-harming patients), the use of medications
(particularly for acute sedation of agitated patients), behavioural disturbances (especially
aggression and violence), and difficulties distinguishing psychiatric from physical
illness to be areas that were problematic, both in terms of knowledge deficit and
confidence.

Additionally, our study found that the confidence of clinical staff was enhanced by
better availability of resources, mostly having access to other clinicians with greater
knowledge and skill in managing mental health patients, but also in relying on other
members of the ED clinical team, and security staff, for support. Security was an
important issue affecting confidence, and a safe ED environment was seen as integral
to optimal management, particularly with violent patients. ED clinicians were largely
aware of their deficiencies, and noted the important contribution of experience to
their confidence.

In line with the quantitative study, ED clinicians perceived risk assessment of self-harming
patients, and behavioural disturbance, particularly in patients with personality disorders,
as key areas where they felt the least confidence. These were areas which both ED
medical and nursing staff rated the highest in terms of desired further training.
Lack of knowledge of available community services however, and difficulties in making
appropriate disposition decisions, were factors that were noted to affect confidence
in our research, but were not reported in the quantitative study, highlighting the
value of this qualitative research to better inform clinical service provision and
education.

Limitations

The sample included clinicians from most regions and grades of medical staff, but
there were no nurses from New South Wales or clinicians from the Australian Capital
Territory recruited for interview. This may limit the generalisability of our findings.

Conclusions

Australian ED clinicians managing patients with mental health-related emergencies
are most concerned about their knowledge deficits in risk assessment, particularly
for self-harming patients, violent and aggressive patients and their management, and
distinguishing psychiatric from physical illness. They report that their confidence
improves with better access to trained psychiatric support staff and in a safe ED
environment. Strategies to enhance the care of patients with mental health presentations
should address these areas of deficit and discomfort.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All authors contributed to the study design, data analysis and writing of the paper,
and have given final approval for publication of the paper. NH conducted the interviews.

Funding

Funded by a competitive grant from the Windemere Foundation.

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